Background: Vasopressors are frequently used in critically ill patients with hemodynamic instability both in the emergency department (ED) as well as intensive care units (ICUs). Typically, vasopressors are given through central venous catheters (CVCs) as opposed to peripheral intravenous (PIV) access due to the concerns about adverse events (i.e. tissue ischemia/necrosis) associated with extravasation through PIVs. In a truly hypotensive, critically ill patient the use of a PIV to administer vasopressors will allow the medication to stabilize the patient sooner and reduce the time to hemodynamic stability. The requirement to start vasopressors through a CVC may delay administration of pressors. Also, performing the insertion of a CVC in a hypotensive patient in an emergency circumstance versus an elective circumstance may increase the risk of adverse events from the procedure itself (i.e. bacteremia, pneumothorax, arterial puncture). Finally, most of the evidence cited for avoiding PIV administration of pressors is a sparse collection of case studies and expert opinion.

85.3% of adverse events occurred from PIVs located at sites distal to antecubital or popliteal fossae

96.8% of adverse events occurred after 4 hrs of infusion from PIV

Major disability and mortality in 9 (4.4%) and 4 (2.2%) of cases respectively

114 extravasation events

75.4% did not result in any tissue injury

75% of adverse events were distal to antecubital and popliteal fossae

Major disability 3 cases (2.7%), and mortality 1 case (0.9%)

7 events were from CVC administration

4 local tissue injury events (3 skin necrosis & 1 gangrene)

Long-term sequelae 3 cases and minor disability 2 cases

Mortality in 1 case

3 extravasation events

No injuries reported

Duration of Vasopressor Infusion

Strengths:

This is the largest review to date looking at the use of vasopressors from PIVs

Limitations:

This was a systematic review, but many of the studies had information abstracted from charts, so there may be some reporting bias (i.e. some complications may not have been documented) which would underestimate complications

This review was only for complications from administration of vasopressor, and not a review of frequency of complications (i.e. instances where no complications occurred)

There was a large inconsistency of reporting among the published studies reviewed. Critical information to analyze the outcomes of interest were missing in a lot of published reports.

Discussion:

Currently administration of vasopressors via peripheral IVs is considered to be unsafe and often discouraged by some due to the concern of local tissue injury from extravasation, but this systematic review found only observational reports of complications of vasopressor infusion from PIVs.

There were 204 local tissue injury events from vasopressor infusion from PIVs, but most (85.3%) of the complications occurred from PIVs distal to the antecubital or popliteal fossae and infusions running >4 hours (96.8%).

Only one event was identified where local tissue injury occurred with infusion of vasopressor via PIV from <1 hour, which was a case of septic shock and an infusion of phenylephrine of unspecified dose via the saphenous vein of the left leg.

There was one RCT comparing complication rates from vasopressor administration of CVC vs PIVs by Ricard et al, which reported increased complication rates from peripheral IVs, but details of the location of the catheters, the nature of the vasopressor, and the duration of infusion were not reported.

The data from this review was derived mostly from case reports and case series and therefore may not be representative or typical of clinical practice, therefore no definitive conclusions can be drawn from this review about safety of PIV administration of vasopressors.

Study Conclusion:

Published data on tissue injury or extravasation from vasopressor administration via peripheral IVs are derived mainly from case reports and further study is warranted to clarify the safety of vasopressor administration via PIVs.

Clinical Take Home Point:

In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.

Hey Salim
Thanks for reviewing this – I saw it to and agree – its a patchwork SR with some interesting trends.

For me its a risk:benefit equation – specifically risk of extravasation vs. risk of leaving the pt hypotensive / in a state of poor perfusion for another few hours until it is possible (resources, staff, skills) to get a CVC sited safely.
A rushed CVC by an occasional operator is also a true clinical risk – hard to pick these out of the data.
But if you take the cases series on face value – the graphic you show does suggest there is a real jump in complications after the 6 -12 hour mark.

So I reckon we in resource -limited places can get by on a good PIVC “till daybreak” if we have crashing patients overnight… or at least until the cavalry arrives in a few hours 😉
My rule – I will only use an IV in an arm if I would be happy to take the patient to theatre for an Emergency Caesarean with that as my access! Its a very practical definition of “Good IVC” in my head!
Thanks
Casey

Great article, as always. I think it’s quite safe to use in at least an AC or more proximal. I could not agree with you more. I think the biggest use I have now is peri-intubation pressors – I will start pressors peripherally if borderline hypotensive and intubating, to attempt to avoid the peri-intubation arrest: “resuscitate before intubate.”

I also think it’s reasonable at times to use peripheral dopamine – I wouldn’t in sepsis – but bradycardia/hypotension secondary to something like hyperkalemia, or a neurogenic shock patient for example – it’s not a huge deal if it extravasates.

Do you happen to know – I went back to the abstract – they found 270 patients that had tissue injury – do you know the total number of patients this was out of? I wonder what the actual rate of occurrence is.

Just had a consultant and registrar laugh and criticize another registrar for transferring a patient on NA infusion running through a 16G 80 mm long Angiocath inserted under US guidance in the basilic vein.

Hi Edward,
Unfortunately the review was in adults 18 years and older. Children were not included so hard to draw conclusions in kids. Not aware of any reviews or large trials or reviews in the pediatric population either.

[…] The fact is that if you have a patient who needs a presser and there’s no central line it’s ok. Yes, it may not be ideal, but if your patient is circling the drain and the BP tanks, what choice do you have. So here’s your education FOAM ammo when confronted by the stank eye. Thanks to REBEL EM for this one! Myth buster: Administration of Vasopressors Through Peripheral Intravenous Access […]